ASSISTANCE DIRECTORY - Hawaii€¦ · FO – Finance Office PPDO – Policy & Program Development...

ASSISTANCE DIRECTORY

For additional information of assistance in the following areas, please contact the indicated office below: PROVIDER INQUIRIES

Agent Authorization Form DHS/MQD/HCMB 692-8099 P.O. Box 700190 Kapolei, HI 96709-0190 Centers for Medicare & Medicaid www.cms.gov/medicaid (CMS)

Clinical Laboratory Improvement Department of Health 453-6662 Amendments (CLIA) applications, CLIA Program enrollment and certification 2725 Waimano Home Road Pearl City, HI 96782 Claims Correspondence Inquiry Xerox State Health Care Oahu: Forms Provider Inquiry Unit 952-5570 1132 Bishop Street Suite 800 Neighbor Islands: Honolulu, HI 96813 1-800-235-4378 Claim Forms: (CMS) 1500 Rainbow Printers, Inc. 593-9782 875 Waimanu St. Room 507 Honolulu, HI 96813 UB-04 Standard Register 536-9351 737 Bishop Street, Suite 1850 Honolulu, HI 96813 DHS – Department of Human Services HCSB- Health Care Services Branch DE – Eligibility Branch FO – Finance Office PPDO – Policy & Program Development Office

PROVIDER MANUAL: APPENDIX I Page A1 to A62 GENERAL

Assistance Directory Page A01 to A10

Claim Forms (Cont): ADA 1999 v. 2000 Rainbow Printers, Inc. 593-9782 875 Waimanu Street Room 507 Honolulu, HI 96813 Pharmacy (Drugs) Xerox Stare Healthcare PBMS Rx Help Desk: Attn: Hawaii Medicaid Paper Claims 1-877-439-0803 PO Box 967 Henderson, NC 27536-0967 Or www.himed-questffs.org Claims Filing (EMC): CMS 1500, UB-04 Xerox State Healthcare Oahu: Provider Inquiry Unit 952-5570 1132 Bishop St. Suite 800 Neighbor Islands: Honolulu, HI 96813 1-800-235-4378 Pharmacy (Drugs) Xerox State Healthcare PBMS (Rx) Help Desk: Attn: Hawaii Medicaid Paper Claims 1-877-439-0803 PO Box 967 Henderson, NC 27536-0967

Claims Filing (Hard Copy): CMS 1500. UB-04 Xerox State Healthcare P.O. Box 1220 Honolulu, HI 96807-1220

DHS – Department of Human Services HCSB- Health Care Services Branch DE – Eligibility Branch FO – Finance Office PPDO – Policy & Program Development Office



http://www.himed-questffs.org/

Claim Filing (Hard Copy) (cont.): Pharmacy (Drugs) Xerox State Healthcare PBMS (Rx) Help Desk: Attn: Hawaii Medicaid Paper Claims 1-877-439-0803 PO Box 967 Henderson, NC 27536-0967

Claims Inquires: Medical Xerox State Healthcare Oahu:

Provider Inquiry Unit 952-5570 1132 Bishop St. Suite 800 Neighbor Islands: Honolulu, HI 96813 1-800-235-4378

Hours of Operation: Monday – Friday 7:30 a.m. – 5:00 p.m. Except State Holidays Dental Hawaii Dental Services Oahu: 1-808-529-9345 Toll Free: 1-855-819-9117

Pharmacy (Drugs) Xerox State Healthcare PBMS (Rx) Help Desk: Attn: Hawaii Medicaid Paper Claims 1-877-439-0803 PO Box 967 Henderson, NC 27536-0967

Or www.himed-questffs.org

Coupon Request DHS/MQD/EB/Branch Unit/ 587-3540 Eligibility Worker Eligibility Determination DHS/MQD/EB/Branch Unit 587-3540 Information DHS Medicaid Online https://hiweb.statemedicaid.us DHS – Department of Human Services HCSB- Health Care Services Branch DE – Eligibility Branch FO – Finance Office PPDO – Policy & Program Development Office



http://www.himed-questffs.org/

https://hiweb.statemedicaid.us/

Eligibility Verification (cont.): Enrollment Call Center DHS/MQD Oahu: P.O. Box 700190 524-3370 Kapolei, HI 96709-0190 Neighbor Islands: 1-800-316-8008 Point of Sale Systems EMDEON EDI Customer Service Voice: (Pacific Standard Time: 5:00 1-800-333-0263 a.m. – 5:00p.m) Fax: Or Email at: 1-615-843-2539

[email protected] State Administrative Hearing DHS/Administrative Appeals Office P.O. Box 339 Honolulu, HI 96809-0339 Fraud or Abuse Reporting DHS/FIS/FO 524-3370 1001 Kamokila Blvd. Rm. 317 Kapolei, HI 96707 Or Medicaid Investigation Division 586-1058 Dept. of Attorney General 333 Queen Street Honolulu, HI 96813 Hamamatsu PET Center The Queen’s Medical Center 537-7077 Fax: 537-7813 Immunization Recommendations - Centers for Disease Control: National Immunization Program www.cdc.gov/nip DHS – Department of Human Services HCSB- Health Care Services Branch DE – Eligibility Branch FO – Finance Office PPDO – Policy & Program Development Office



http://www.cdc.gov/nip

MQD Provider Hotline DHS/MQD/Provider Hotline 952-5570 1-800-235-4378 Hours of Operation: Monday – Friday 7:30 a.m. – 5:00 p.m. Except State Holidays Medicaid Fee (Payment) Schedule Xerox State Healthcare Oahu:


Medical Authorizations (Medical): Instructions Xerox State Healthcare Oahu:


Urgent or Conditional Xerox State Healthcare Authorization Requests Provider Inquiry Unit Fax: 952-5562 1132 Bishop St. Suite 800 Honolulu, HI 96813 Dental Services Hawaii Dental Services (HDS) Oahu: 700 Bishop St. Ste. 750 1-800-529-9345 Honolulu, HI 96813 1144 – Medical Services Xerox State Healthcare Fax: 952-5562 (including Organ P.O. Box 1220 Transplants) Honolulu, HI 96807-1220




Medical Authorizations (Medical) - Cont.:

1144 – PET Scans The Queen’s Medical Center 537-7077 Hamamatsu PET Center Fax: 537-7813

1144b Xerox State Healthcare PBMS (Rx) Help Desk: Attn: Hawaii EMC Billing 1-877-439-0803 PO Box 967 Henderson, NC 27536-0967

208 Community Caser Mgmt. Corp. (CCMC) 792-1051 P.O. Box 2818 Fax 792-1098 Aiea, HI 96801 1-866-486-8031

1018 Xerox State Healthcare Fax: 952-5562 P.O. Box 1220 Honolulu, HI 96807-1220 1135 DHS/FMO/BPS P.O. Box 339 Honolulu, HI 96809-0339 1147/1147a/1147e Health Services Advisory Group Oahu (HSAG) 808-440-6000 1440 Kapiolani Blvd. Fax: 440-6009 Ste. 1110 Honolulu, HI 96814-3600




Medical Authorizations (Medical) - Cont.:

1144 – PET Scans The Queen’s Medical Center 537-7077 Hamamatsu PET Center Fax: 537-7813 1150/1150c DHS/MQD/HCSB Fax: 692-8131 P.O. Box 700190 Kapolei, HI 96709-0190

Payment Checks (Lost Checks, Expired Checks, Returned Checks) For Medical Payments Xerox State Healthcare Oahu: P.O. Box 1480 952-5570 Honolulu, HI 96807-1480 Neighbor Islands: 1-800-235-1378 For Drug Payments Xerox State Healthcare PBMS (Rx) Help Desk: Attn: Hawaii Medicaid Paper Claims- Refunds 1-877-439-0803 P.O. Box 967 Henderson, NC 27536-0967




Provider Information Form: Applications, Provider Address DHS/MQD/HCSB 692-8099 Changes, Provider Status P.O. Box 700190 Changes, Kapolei, HI 96709-0190 Provider Terminations Provider Release of Information DHS/MQD/FO/TPL 692-8074 P.O. Box 700190 Kapolei, HI 96709-0190 State of Hawaii Organ Tissue Transplant (SHOTT) Program: Claim Submissions and Koan Risk Solutions Inc. 469-4500

Fax: 808-356-1645 Claim Inquiries SHOTT Program 1580 Makaloa St. Ste. 550 Case Management and 469-4505 Issues related specific Medical Services Timely Filing Waiver DHS/MQD/FO- Timely Filing Dept. Request: 1001 Kamokila Blvd. Rm. 317 Kapolei, HI 96707 DHS – Department of Human Services HCSB- Health Care Services Branch DE – Eligibility Branch FO – Finance Office PPDO – Policy & Program Development Office



Haprcics BENEFICIARY QUESTIONS:

Benefits and MQD Customer Services 524-3370 and all other Information: 1-800-316-8005 Health Plans Aloha Care 1-877-973-0712 HMSA 1-800-440-0640 Kaiser Permanente 1-800-651-2237 Ohana Health Plan 1-888-846-4262 United Healthcare 1-888-980-8728

Payment Information DHS/MQD/FO 692-7979 (Subrogation for accident P.O Box 700190 Related cases) Kapolei, HI 96709-0190

Reporting Fraud or Abuse DHS/MQD/FO/FIS 524-3370 1001 Kamokila Blvd. Rm.317 Kapolei, HI 96707 DHS – Department of Human Services HCSB- Health Care Services Branch DE – Eligibility Branch FO – Finance Office PPDO – Policy & Program Development Office



Medical Assistance Applications Unit: Oahu 587-3521 Fax: 587-3543

East Hawaii (Hilo) 933-0339 Fax: 933-0344

West Hawaii (Kona) 327-4970 Fax: 327-4975

Maui 243-5780 Fax: 243-5788

Kauai 241-3575 Fax: 241-3583

Molokai 553-1758 Fax: 553-3833

Lanai 565-7102 Fax: 565-6460 DHS – Department of Human Services HCSB- Health Care Services Branch DE – Eligibility Branch FO – Finance Office PPDO – Policy & Program Development Office



Medical Assistance Coupon

PROVIDER MANUAL: APPENDIX 1 Pages A1 to A62GENERALMedical Assistance Coupon Page A 11

PROVIDER MANUAL: APPENDIX 1 Pages A1 to A62GENERALPolicy Manual Definitions Page A12 of A 19

POLICY MANUAL DEFINITIONS

1. ABDAged, blind and disabled

2. Acute Care ServicesMedically necessary services as described in this Manual that are covered for Medicaidrecipients who are eligible for services. The services are provided through contractualagreements with program contractors or on a fee for service basis.

3. AllowanceThe amount paid by Medicaid for health care or a service.

4. AMAAmerican Medical Association

5. ApplicantAn individual who completes and signs the Med-QUEST application form on behalf ofhimself or herself and/or other family dependents.

6. Attending PhysicianA physician (M.D.) or a doctor of osteopathy (O.D./D.O.) who is identified by theindividual as having the most significant role in the determination and delivery of theindividuals medical care.

7. Behavioral Health Managed Care PlanThe DHS contracted managed care plan that provides behavioral health services with afocus on case management to enrolled seriously mentally ill (SMI) adults.

8. Behavioral Health ServicesServices provided to persons who are emotionally disturbed, mentally ill, abuse or areaddicted to alcohol and drugs.

9. BenefitsThose health services to which the recipient is entitled under Medicaid.

10. ChargeThe amount charged by the provider for services rendered to a recipient.


11. ClaimA legal document submitted to Medicaid or its fiscal agent for payment.

12. Clean ClaimA claim that does not require further written information or substantiation in order tomake payment.

13. CMSThe Centers for Medicare and Medicaid Services formerly referred to as HCFA. Thenew organization is grouped into three centers; the Center for Beneficiary Choices(Medicare Choice Plus), the Center for Medicare Management (FFS Medicare), and theCenter for Medicaid and State Operations (State administered programs includingMedicaid, S-CHIP, and insurance regulation).

14. Covered ServicesThose services and benefits to which the recipient is entitled under a medical assistanceprogram.

15. CPT-4Common Procedural Terminology, a coding structure for medical procedures issued bythe American Medical Association.

16. CrisisA period in which the individual requires continuous care to achieve palliation ormanagement of acute medical symptoms.

17. DaysCalendar days

18. Dental EmergencyAn oral condition requiring immediate dental services to control bleeding, eliminate acuteinfection, treat injuries to teeth or supportive structures, or provide palliative treatmentwithout delay.

19. DependentA recipient’s legal spouse or dependent child who meets all eligibility requirements.

20. Dependent ChildA child under 19 for whom an applicant or recipient is legally responsible.


21. DHSDepartment of Human Services, the State Agency responsible for administering Medicaidfor Hawaii.

22. DirectorDirector of the Department of Human Services, State of Hawaii.

23. DSM IVDiagnostic and Statistical Manual of Mental Disorders, 4th Edition.

24. Early and Periodic Screening, Diagnosis and Treatment (EPSDT)EPSDT is a federally mandated program for children up to age 21 which emphasizes theimportance of prevention, early detection of medical, dental and behavioral healthconditions and timely treatment of conditions detected as a result of screening.

25. Effective Date of EnrollmentThe date from which an individual is covered by Medicaid.

26. Eligibility DeterminationA process of determining, upon receipt of written application, whether an individual orfamily is eligible for benefits such as health services.

27. Eligible PersonA person who has been determined to qualify for health services pursuant to regulationsbut who is not enrolled in a health plan or with a program contractor. (Also seedefinition for recipient.)

28. EMCElectronic media claim

29. Emergency ConditionA medical condition manifesting itself by acute symptoms of sufficient severity(including sever pain) such that a prudent layperson, who possesses an averageknowledge of health and medicine, could reasonably expect the absence of immediatemedical attention to result in placing the health of the individual (or with respect topregnant woman, the health of the woman or her unborn child) in serious jeopardy,serious impairment to body functions or serious dysfunction of any bodily organ or part.

30. Emergency Medical ServiceMedical services provided after the sudden onset of an emergency medical condition andresulting in an unscheduled or unplanned visit, admission or other medical services toassess, relieve and/or treat the emergent condition.


31. Explanation of Benefits (EOB)The statement mailed to providers detailing the claims paid or denied, includingexplanations for those denied.

32. Fee-For-Service (FFS)A method of payment when a physician or other health care provider bills and is paid foreach service. Also refers to services reimbursed directly by the Med-QUEST Divisionfor eligible persons not enrolled with a health plan or program contractor. See definitionof Recipient for individuals enrolled with the FFS Program.

33. FQHCFederally qualified health center

34. Fiscal Year or FYThe twelve month period for the State fiscal year from July 1 through June 30.

35. HAWIHawaii Automated Welfare Information System. The State of Hawaii certified system,which maintains eligibility information for TANF, Food Stamp and medical assistancerecipients.

36. HCFAFormerly stood for the Health Care Financing Administration, U.S. Department of Healthand Human Services which was responsible for administering Medicaid. The new namefor HCFA is Centers for Medicare and Medicaid Services (CMS).

37. HCFA 1500Nationally accepted claim form for non-institutional billing, excluding dental andpharmacy claims.

38. HCPCSHealth Care Financing Administration’s Common Procedure Coding System, created byHCFA and required when reporting procedures and services provided to Medicare andMedicaid beneficiaries; includes HCFA and CPT codes.

39. Health AssessmentAn evaluation of the health status of an individual, including an evaluation of theindividual’s lifestyle and need for continuing health services.


40. Health PlanAny health care organization, insurance company or health maintenance organization,which provides covered services on a risk basis to enrollees in exchange for premiumpayments.

41. Home and Community Based ServicesWaiver services provided, in lieu of institutionalization, to Medicaid recipients whoreside in their own home or in an approved alternative residential setting in order tohabilitate, rehabilitate or maintain the recipient’s highest level of functioning.

42. Hospice ServicesPalliative and supportive services provided to terminally ill recipients through an agencyor organization licensed and Medicare certified as a hospice. Services may be providedto recipients in their own home, an approved alternative residential setting, or aninstitutional setting.

43. HospitalAny hospital in the service area to which a recipient is admitted to receive hospitalservices pursuant to arrangements made by a physician.

44. Hospital ServicesExcept as expressly limited or excluded in the manual or contract, those medicallynecessary services for registered bed patients that are generally and customarily providedby acute care general hospitals in the service area and prescribed, directed or authorizedby the attending physician.

45. ICD-9-CMInternational Classification of Diseases, Ninth Edition – Clinical Modification, aclassification system and coding structure of diseases.

46. Length of StayThe number of days for which inpatient services are provided, including the day ofadmission and excluding the day of discharge.

47. MedicaidA Federal/State program authorized by Title XIX of the Social Security Act, as amended,which provides Federal matching grants for a medical assistance program for recipientsof federally aided public assistance and SSI benefits and other specified groups.

48. Medical OfficeAny outpatient treatment facility staffed by a physician.


49. Medical ServicesExcept as expressly limited or excluded by contract, those medically necessaryprofessional services of physicians, other health professionals and paramedical personnelthat are generally and customarily provided in the service area and performed, prescribedor directed by the attending physician.

50. Medically NecessaryThose covered services provided by a physician or other licensed practitioner of thehealing arts within the scope of their practice under State law that follows standardmedical practice and is deemed essential and appropriate for the diagnosis or treatment ofa particular illness or injury.

51. MedicareA federally funded program that primarily provides medical coverage for persons whoare 65 years of age and older, disabled, or have end-stage renal disease (ESRD).

52. MonthsCalendar months.

53. Outpatient HospitalHospital services and supplies furnished in the hospital outpatient department oremergency room and billed by a hospital for the care of a patient who is not a registeredbed patient (i.e. not admitted to acute inpatient care).

54. Own HomeThe Medicaid recipient’s place of residence pursuant to regulations. This does notinclude approved alternative residential settings.

56. PhysicianThe physician is licensed in Hawaii and is either a M.D. (Doctor of Medicine) or a D.O.(Doctor of Osteopathy).

57. Plan of CareThe proposed, individualized regimen of services, which is prepared by the serviceprovider and includes measurable goals and objectives for the outcome of services.

58. Prepaid PlanA health plan for which premiums are paid on a prospective basis, irrespective of the useof services.


59. Prior Authorization (PA)Process by which health plans, program contractors, and the Med-QUEST Divisiondetermine in advance whether a medical service is appropriate and will be covered forpayment.

60. Private Health Insurance PolicyAny health insurance program, other than disease-specific or accident-only policy, forwhich a person pays for insurance benefits directly to the carrier rather than throughparticipation in an employer or union, sponsored program.

61. Program ContractorAn organization, which contracts with the Med-QUEST Division to execute the provisionof a comprehensive package of services to recipients, enrolled with the programcontractor.

62. ProviderAn individual, clinic, or institution, including but not limited to physicians, osteopaths,nurses, and hospitals responsible for the provision of health services.

63. RecipientAny individual or family dependent who meets all eligibility requirements and is enrolledin Med-QUEST.

64. RepresentativeA person who is, because of the recipient’s mental or physical incapacity, authorized inaccordance with state law to act in their stead.

65. RespiteShort-term care provided to the individual only when necessary to relieve the family orother persons caring for the individual.

66. S-CHIPThe State Children’s Health Insurance (S-CHIP) means the program that was createdthrough enactment of Title XXI of the Social Security Act in the Federal BalancedBudget Act of 1197. This program allows states to expand health insurance coverage foruninsured children up to age 19 with family incomes up to 200% of the federal povertylevel. These children receive all the benefits of the EPSDT program.

67. SEDSeverely emotionally disturbed (SED) describes children from birth to age 21 whom, asthe result of a mental, behavioral or emotional disorder of a sufficient duration to meetdiagnostic criteria. These children exhibit functions, which interferes substantially withtheir family, school, or community activities.


68. Service DateDate on which a health care service was rendered by a provider to a recipient.

69. SMISeriously mentally ill, describes adults (copy definition from BHMCO RFP)

70. SSIThe Supplemental Security Income (SSI) program is administered by the Social SecurityAdministration like Social Security through funding by the federal government and theState. SSI pays monthly benefits to people, who aside from meeting certainrequirements, must be age 65 or older, blind or disabled with limited income andresources. SSI differs from Social Security benefits in that they are not based on priorwork history of either the recipient or a family member.

71. Standard Medical PracticeMost physicians in the nation regard the services as safe and effective. If a service is inits trial stages (e.g., experimental because it is used in research on animals orinvestigative because it is or has been performed on a limited number of people), theservice is not considered standard medical practice for purposed of benefit payment.

72. StateState of Hawaii

73. Suspended ClaimA claim that requires further action or review before it is paid or denied.

74. TANFTemporary Assistance to Needy Families. Time limited public financial assistanceprogram that replaced ADFC that provides cash grant and medical benefits to adults andchildren.

75. Terminally IllA medical prognosis determined and documented by a physician that recipient’s lifeexpectancy is six months or less if the recipient’s illness runs its normal course.

76. UB-92Nationally designed claim form for institutional billings.

77. Urgent CareThe diagnosis and treatment of medical conditions which are serious or acute but pose noimmediate threat to life and health but which requires medical attention within 24 hours.

1. Date of Inquiry 2. Provider Name (Last, First, Middle Initial)

3. Provider Number 4. Address: ☐Pay to Address ☐Service Address

5. Telephone Number 6. Name of Contact

7. Claim Number (if applicable) 8. Purpose of Inquiry: ☐Questionable Payment ☐Claim Status

☐Claims Filing Procedure ☐Other

9. Patient Name 10. Patient ID Number

11. Dates of Service 12. Payment Date 13. Charge 14. Allowance

15. Remarks

16. Response to Provider: (For Office Use Only) Completed by __________________ Date ____________

☐ Clam Paid on ______________________ Amount ______________________________________________

☐ Denied on _________________________ Reason: ______________________________________________

☐ Claim sent to Claims Dept. for reprocessing. _________________________________________________

☐ Patient name and ID # not in DHS files. ______________________________________________________

☐ Claim is in the processing system. Please allow additional processing time. ______________________

☐ Claim is being researched. (We are currently working to resolve this issue.) ______________________

☐ Unable to match above claim data with computer file data. __________________________________

☐ Please submit claim with:

☐ Medicare/TPL EOMB

☐ Approved waiver of filing deadline

☐ Other

☐ Claim date exceeds one year filling deadline Comments: ___________________________________________________________________________________ ______________________________________________________________________________________________

______________________________________________________________________________________________

Last revised 02/14 FORM 239

☐ Submit copy of FFS and Waiver claim to: Hawaii Medicaid Fiscal Agent Claims P.O. Box 1220, Honolulu, HI 96807-1220

Hawaii Medicaid Fiscal Agent 1132 Bishop Street Ste. 800Honolulu, HI 96813

* Do not use this form for claim adjustments. Send resubmissions to the appropriate Hawaii Medicaid Fiscal Agent Claim PO Box.

☐ Submit filing waiver request letter to: DHS/MQD/FO, 1001 Kamokila Blvd., Ste. 317, Kapolei, HI 96707

FORM 239 Medicaid Correspondence Inquiry

Form

Instructions for Medicaid Correspondence Inquiry Form 239

A. Provider Information

1. Date of Inquiry – Self Explanatory.

2. Provider Name – Self Explanatory.

3. Provider Number – Enter the Medicaid provider number or National Provider

Identifier.

4. Address- Provide the mailing address to which the inquiry response is to be mailed

and check if it is a “Pay to” or “Service” address.

5. Telephone Number – Indicate a contact number of the person why may be contacted

if additional information is required.

6. Name of Contact – Provide the name of the person who may be contacted if

additional information is required.

B. Inquiry Information

7. Claim Number – If applicable, indicate the claim number of the claim in question.

This number is shown on the remittance advice.

8. Purpose of Inquiry – Check the applicable blocks (s). “Other” inquiries must be

specified. Use lines to provider additional information to clarify inquiry. If more than

one inquiry is being made on the form, complete the second inquiry portion of the

form. Depending on the number of inquiries being submitted, it may be necessary to

complete more than one inquiry form (239).

9. Patient Name – Enter the patient’s full name in “last name, first name” order if

inquiring about a claim. Do not use nicknames. Leave blank for general inquiries not

specific to a claim.

10. Patient ID number – Enter the Medicaid ID number of the patient identified in

number 9 above. The number should consist of a 10-digit number. This number must

be the same as entered on the submitted claim in question.

11. Dates of Service – Provide the “from” and “to” range of service dates in question.

12. Payment Date – If applicable, provide the date of the remittance advice containing the

payment determination of the claim. Leave blank for claim status inquiries for

outstanding claims.

13. Change – Provider the net charge billed to Medicaid.

14. Allowance – If applicable, provide the Medicaid allowance made toward the claim.

15. Remarks – Provider any additional information, if applicable, that may clarify an

inquiry.

Remittance Advice

PROVIDER MANUAL: APPENDIX 1 Pages A1 to A62GENERALRemittance Advice Components and Samples Pages A22 of A48

GENERAL INFORMATION

The Medicaid fee-for-service Remittance Advice provides information about how claims werepaid or voided and why claims were denied.

The Remittance Advice is generated at least weekly and mailed to the billing provider. If the billingprovider has submitted claims for multiple service providers, the Remittance Advice will contain asection for each.

The Non-Facility Remittance Advice is mailed to providers who bill on the HCFA 1500 andAmerican Dental Association (ADA) claim forms. The Facility Remittance Advice reportsinformation related to services billed on the UB-92 claim form.

Each Remittance Advice is divided into five sections:

Paid claims

Adjusted claims

Denied claims

Voided claims

Claims in process

This section includes claims reported on a previous Remittance and still in process.

The last page of each Remittance Advice is the Processing Notes page. The page provides analphabetical listing of denial reason codes and pricing explanation codes. Each is listed only onceeven if it applies to multiple claims.

ADDRESS PAGE AND FINANCIAL SUMMARY

The Address Page (Remit to Address) of the Remittance Advice displays the billing provider’sname and pay-to mailing address.

The Financial Summary page reports check and invoice data. If all claims are in process ordenied, the page will indicate “No Active Invoices.”

Information reported on the Financial Summary page includes:

BILLING PROVIDER ID number plus locator codes and name

SERVICE PROVIDER ID number plus locator codes and name.

TAX ID of the billing provider.

PAYMENT DATE is the check date.

PAY FOR CATEGORY.

Remittance Advice


Only the Acute Fee for Service Category is applicable at this time.

CHECK NUMBER.

INVOICE DATE is the date Medicaid processed the claims for payment.

INVOICE NUMBER links payments to the services that generated the payment.

TYPE column will indicate “CR” if the provider has a credit.

GROSS AMOUNT is the total remitted for each Pay For Category.

A negative total means no payment on this remittance.

Gross Amount and Net Amount are usually equal unless there is a credit memo (negativeinvoices or recouped claims).

DISCOUNT is never used for Medicaid fee-for-service providers.

NET AMOUNT is the check amount for each Pay for Category.

If there are outstanding credit memos, this will show zero until enough approved claimsare processed to offset the credit.

NON-FACILITY REMITTANCE ADVICE SECTIONS

The Paid Claims section for both acute and long term care non-facility claims displays thefollowing data:


BILLING PROVIDER ID number plus locator codes and name.


INVOICE NUMBER matches the number on the Financial Summary.

CHECK NUMBER matches the number on the Financial Summary.

PAYMENT DATE is the date of the reimbursement check.


FORM TYPE will be HCFA 1500 or ADA form.

HI ID is the HAWI ID of the recipient.

RECIPIENT is the ID number submitted on the claim.

NAME of the recipient as recorded in the Medicaid system.

NON-FACILITY REMITTANCE ADVICE SECTIONS (CONT.) PATIENT ACCOUNT NUMBER is the number entered on the claim in the patient account

number field.

Remittance Advice


PRICE EXPL is the pricing explanation code.

Definitions are printed on the Processing Notes page.

An asterisk ( * ) next to a code denotes how the ALLOWED AMOUNT was determined(e.g., MCC = Medicare Coinsurance, MAX = maximum allowed charge/capped fee, etc.).

CRN is the Claim Reference Number that is unique to each claim and remains the same overthe life of the claim.

STATUS DATE is the most recent date the claim was adjudicated (attained “Paid” status).

SERVICE CD/MODIFIER is the CPT/HCPCS procedure code submitted on the claim.

Any procedure modifier would be printed below the procedure code.

DATES OF SERVICE displays the From and Through dates of service submitted on theclaim.

If dates are the same, only one date is displayed.

BILLED AMOUNT submitted on the claim.

BILLED UNITS reflects the number of units billed on the claim.

ALLOWED UNITS reflects the Medicaid allowed number of units.

ALLOWED AMOUNT may be based on the Medicaid capped fee (Medicaid fee schedule), aprovider specific rate, Medicare Coinsurance and Deductible, etc.

NET PAID AMOUNT is the ALLOWED AMOUNT minus any deductions.

The following summary is listed at the end of each Non-facility Paid Claims section:

NUMBER OF CLAIMS is the total number of claims in the Paid Claims section.

TOTAL BILLED AMOUNT for all claims in the Paid Claims section.

TOTAL REMIT AMOUNT for all claims in the Paid Claims section.

The Denied Claims section for non-facility claims displays much of the same data as the PaidClaims section:



TAX ID.NON-FACILITY REMITTANCE ADVICE SECTIONS (CONT.)

FORM TYPE.

HI ID.

RECIPIENT.

Remittance Advice


NAME.

REASON CDS lists the denial reason code(s).


PATIENT ACCOUNT NBR.

CRN is the Claim Reference Number of the claim.

Resubmissions of denied claims must reference this number.

SERVICE CD/MODIFIER.

DATES OF SERVICE.

BILLED AMOUNT.

BILLED UNITS.

The following summary is listed at the end of each Non-facility Denied Claims section:

NUMBER OF CLAIMS in the Denied Claims section.

TOTAL BILLED AMOUNT for all claims in the Denied Claims section.

The Adjusted Claims section for non-facility claims displays much of the same data as the PaidClaims section:

INVOICE DATE.



INVOICE NUMBER.

CHECK NUMBER.

PAYMENT DATE.

TAX ID.

FORM TYPE.

HI ID.NON-FACILITY REMITTANCE ADVICE SECTIONS (CONT.)

RECIPIENT.

NAME.

PATIENT ACCOUNT NUMBER.

PRICE EXPL.

CRN is the Claim Reference Number of the original claim.

Remittance Advice


The claim retains this number regardless of the number of times it is adjusted.



DATES OF SERVICE.

BILLED AMOUNT.

BILLED UNITS.

ALLOWED UNITS.

ALLOWED AMOUNT may be based on the Medicaid capped fee (i.e. Medicaid feeschedule), Medicare Coinsurance and Deductible, etc.

The PREVIOUSLY PAID amount is “backed out” and displayed as a negative number.

NET PAID AMOUNT is the difference between the new ALLOWED AMOUNT and thePREVIOUSLY PAID amount.

This amount could be negative if the adjusted Allowed Amount is less than the originalAllowed Amount.

The following summary is listed at the end of each Non-facility Adjusted Claims section:

NUMBER OF CLAIMS is the total number of claims in the Adjusted Claims section.

TOTAL BILLED AMOUNT for all claims in the Adjusted Claims section.

TOTAL REMIT AMOUNT for all claims in the Adjusted Claims section.

The Voided Claims section for non-facility claims displays much of the same data as the PaidClaims section:

INVOICE DATE.



INVOICE NUMBER.NON-FACILITY REMITTANCE ADVICE SECTIONS (CONT.)

CHECK NUMBER.

The Voided Claims section will only have a check number if the paid and adjusted claimsduring the payment cycle total more than amount being recouped as voids.

PAYMENT DATE.

Voided Claims section for non-facility claims (Cont.):

TAX ID.

Remittance Advice


FORM TYPE.

HI ID.

RECIPIENT.

NAME.


PRICE EXPL.


The claim retains this number when it is voided.

STATUS DATE.


DATES OF SERVICE.

BILLED AMOUNT.

BILLED UNITS reflects the number of units billed on the claim.

ALLOWED UNITS is the Medicaid allowed number of units.

ALLOWED AMOUNT is displayed as a negative amount.

Any previous deductions are “backed out” and displayed as a positive number.

NET PAID AMOUNT is a negative number showing the amount recouped.

The following summary is listed at the end of each Non-facility Voided Claims section:

NUMBER OF CLAIMS in the Voided Claims section.

TOTAL BILLED AMOUNT for all claims in the Voided Claims section.

TOTAL RECOUPED AMOUNT for all claims in the Voided Claims section.NON-FACILITY REMITTANCE ADVICE SECTIONS (CONT.)

The Claims in Process section of the Remittance Advice for non-facility claims displays allclaims that have not been adjudicated. The Claims in Process section displays much of the samedata described previously:



TAX ID.

FORM TYPE.

HI ID.

Remittance Advice


RECIPIENT.

NAME.



Inquiries about the claim should reference this number.


DATES OF SERVICE.

BILLED AMOUNT.

BILLED UNITS.

The following summary is listed at the end of each Non-facility Claims in Process section:

NUMBER OF CLAIMS is the total number of claims in process.

TOTAL BILLED AMOUNT for all claims in process.

The Processing Notes section is the last section of the Non-facility Remittance Advice package.The Processing Notes section displays the following data:



NOTE is an alphabetical listing of processing codes (denial or void reason codes, pricingmethod codes, etc.).

Each code is listed only once even if applicable to multiple claims.

NON-FACILITY REMITTANCE ADVICE SECTIONS (CONT.) TYPE lists the type of code.

M = Pricing Method

P = Pricing Type

R = Reason Code

T = Tier

X = Modifier

DESCRIPTION is the description of a processing note code.

Example:

H199.1R CLAIM RECEIVED PAST 9 MONTH LIMIT

Remittance Advice


FACILITY REMITTANCE ADVICE SECTIONS

The Paid Claims section for facility claims displays the following data:




INVOICE NUMBER matches the number on the Financial Summary.

CHECK NUMBER matches the number on the Financial Summary.

PAYMENT DATE is the date of the reimbursement check.


FORM TYPE will be Inpatient (includes inpatient hospital and nursing home) or Outpatient(includes outpatient hospital, free standing dialysis centers, hospice, and birthing centers).

HI ID of the recipient.

RECIPIENT is the ID number submitted on the claim.

NAME of the recipient as recorded in the Medicaid system.

PATIENT ACCOUNT NUMBER is the number entered on the claim in the patient accountnumber field.


Definitions are printed on the Processing Notes page.FACILITY REMITTANCE ADVICE SECTIONS (CONT.)

An asterisk ( * ) next to a code denotes how the ALLOWED AMOUNT was determined.

For hospital inpatient claims, tier(s) into which the claim was classified are displayed(e.g., MAT = Maternity tier).

For nursing home claims, codes may indicate PDM (per diem) or MCC (MedicareCoinsurance).

TIER DATA displays the inpatient tier classification, number of accommodation days billed. Medicaid allowed days for tier(s) and reason codes for any disallowed and cutback days.

CRN is the Claim Reference Number that is unique to each claim and remains the same overthe life of the claim.


DATES OF SERVICE displays the From and Through dates of service submitted on theclaim.

BILLED AMOUNT submitted on the claim.

Remittance Advice


BILLED UNITS reflects accommodation days for inpatient claims.

ALLOWED UNITS reflects accommodation days for inpatient claims.

ALLOWED AMOUNT may be based on the tier per diem, the Medicaid capped fee(Medicaid fee schedule) the provider’s specific rate or Medicare Coinsurance andDeductible.

NET PAID AMOUNT is the ALLOWED AMOUNT minus any deductions.

The following summary is at the end of each Paid Claims section:

NUMBER OF CLAIMS, both inpatient claims and outpatient, in the section.

TOTAL BILLED AMOUNT for all claims in the section.

TOTAL REMIT AMOUNT for all claims in the section.

The Denied Claims section for both acute and long term care facility claims (Exhibit 28-11)displays much of the same data as the Paid Claims section:

BILLING PROVIDER ID.

SERVICE PROVIDER ID.

TAX ID.

FORM TYPE.

HI ID.

RECIPIENT.

FACILITY REMITTANCE ADVICE SECTIONS (CONT.) NAME. REASON CDS lists the denial reason code(s).


PATIENT ACCOUNT NBR.


Resubmissions of denied claims must reference this number.

DATES OF SERVICE.

BILLED AMOUNT.

BILLED UNITS.

This field is not populated for outpatient UB-92 claims.

The following summary is listed at the end of each Denied Claims section:

Remittance Advice


NUMBER OF CLAIMS in the Denied Claims section.

TOTAL BILLED AMOUNT for all claims in the Denied Claims section.

The Adjusted Claims section for facility claims displays much of the same data as the PaidClaims section:

INVOICE DATE.



INVOICE NUMBER.

CHECK NUMBER.

PAYMENT DATE.

TAX ID.

FORM TYPE.

HI ID.

RECIPIENT ID.

NAME.


FACILITY REMITTANCE ADVICE SECTIONS (CONT.) PRICE EXPL is the pricing explanation code.

TIER DATA. CRN is the Claim Reference Number of the original claim.

The claim retains this number regardless of the number of times it is adjusted.

STATUS DATE.

DATES OF SERVICE.

BILLED AMOUNT.

BILLED UNITS.

ALLOWED UNITS.

ALLOWED AMOUNT may be based on the tier per diem, Medicaid capped fee (Medicaidfee schedule), the provider’s specific rate or Medicare Coinsurance and Deductible.

The PREVIOUSLY PAID amount is “backed out” and displayed as a negative number.

NET PAID AMOUNT is the difference between the new ALLOWED AMOUNT and thePREVIOUSLY PAID amount.

Remittance Advice


This amount could be negative if the adjusted Allowed Amount is less than the originalAllowed Amount.

The following summary is listed at the end of the Adjusted Claims section:

NUMBER OF CLAIMS, inpatient and outpatient, in the section.


TOTAL REMIT AMOUNT for all claims in the section.

The Voided Claims section for facility claims displays much of the same data as the Paid Claimssection:

INVOICE DATE.



INVOICE NUMBER.

CHECK NUMBER.

PAYMENT DATE.

TAX ID.

FACILITY REMITTANCE ADVICE SECTIONS (CONT.) FORM TYPE.

HI ID.

RECIPIENT ID.

NAME.



TIER DATA.


The claim retains this number when it is voided.

STATUS DATE.

DATES OF SERVICE.

BILLED AMOUNT.

BILLED UNITS.

ALLOWED UNITS.

Remittance Advice


ALLOWED AMOUNT is displayed as a negative amount.

Any previous deductions are “backed out” and displayed as a positive number.

NET PAID AMOUNT is a negative number showing the amount recouped.The following summary is listed at the end of each Voided Claims section:

NUMBER OF CLAIMS, inpatient claims and outpatient, in the section.


TOTAL RECOUPED AMOUNT for all claims in the section.

The Claims in Process section of the Remittance Advice for facility claims displays all claimsthat have not been adjudicated. The Claims in Process section displays much of the same datadescribed previously:



TAX ID.

FORM TYPE.

HI ID.FACILITY REMITTANCE ADVICE SECTIONS (CONT.)

Claims in Process section for both acute and long term care facility claims (Cont.):

RECIPIENT ID.

NAME.



Inquiries about the claim should reference this number.

DATES OF SERVICE.

BILLED AMOUNT.

BILLED UNITS.

The following summary is listed at the end of the Claims in Process section:

NUMBER OF CLAIMS, inpatient and outpatient, claims in process.

TOTAL BILLED AMOUNT for all claims in process.

The Processing Notes section is the last section of the Facility Remittance Advice. It displays thesame type of information as does the Processing Notes section for non-facility claims.

Remittance Advice


WORKING THE REMITTANCE ADVICE

Here are some suggestions for working the Remittance Advice to reconcile claims billed toMedicaid and the status of those claims:

1. Review the Paid Claims section of the Remittance Advice to determine which claims have beenpaid and if those claims are paid correctly. Any errors, such as claims (and associated CRNs)that have not paid the correct number of units should be marked for adjustment. (See Chapter 4Claims Payments, for information on adjusting a paid claim.)

2. Review the Adjusted Claims section of the Remittance Advice. This section will report anyclaims submitted by the provider as adjustments because they were not paid correctly. Ifproblems still exist with a claim, it may be submitted again as another adjustment. This sectionalso will report any claims that were adjusted by Medicaid as a result of an audit or review.

3. Review the Voided Claims section of the Remittance Advice. This section will report anyclaims submitted by the provider as void transactions. There are many reasons a claim may bevoided. These may be claims that have been paid by other insurance and now need to be voidedso that Medicaid can recoup its payment. This section also will report any claims that werevoided by Medicaid as a result of an audit or Medical review recoupment. Providers who believethat a claim was voided in error should contact the Fiscal Agent. Refer to the AssistanceDirectory in this Appendix for the contact information.

4. Review the Denied Claims section of the Remittance Advice. Review the message for eachcode and determine the action necessary to correct the claim. (See Chapter 4, Claims Payments,for information on resubmitting a denied claim.)

Providers who have questions about the Remittance Advice or about resubmitting, adjusting, orvoiding a claim should contact the Fiscal Agent, as indicated in the Assistance Directory of thisAppendix.

Remittance Advice


REPORT ID: FI04W400 HAWAII DHS MED-QUEST DIVISION PMMIS PAGE: 1PROGRAM ID: FI04L400 REMITTANCE ADVICE - REMIT TO ADDRESS RUN:

11/28/98

BILLING PROVIDER: 654321 01

INVOICE DATE: 11/28/98PAYMENT DATE: 10/01/98

PROVIDER NAMESTREET ADDRESS OR P.O. BOXANYTOWN HI 99999

** PLEASE CALL PROVIDER SERVICES FOR QUESTIONS OR CLARIFICATION ABOUT THE CONTENTS OF THIS PACKAGE **** PROVIDER SERVICES MAY BE REACHED AT (808) 952-5570 or 1-800-235-4378

Address page shows billing provider’sname and Pay-To mailing address

Remittance Advice


SAMPLE REMITTANCE ADVICE – FINANCIAL SUMMARY

REPORT ID: FI04W400 HAWAII DHS MED-QUEST DIVISION PMMIS PAGE: 2PROGRAM ID: FI04L400 REMITTANCE ADVICE - FINANCIAL SUMMARY RUN:

11/28/98001549 INVOICE DATE: 11/28/98

BILLING PROVIDER: 654321 01 PROVIDER NAME

TAX ID: 999999999PAYMENT DATE: 12/01/98

CHECK INVOICEPAY FOR CATEGORY NUMBER DATE INVOICE NUMBER TYPE GROSS AMOUNT DISCOUNT NET AMOUNT----------------------------------------------------------------------------------------------------------------------------------------------------------------ACUTE FEE-FOR-SERVICE 48746 11/28/98 A9800000000001 1033.21 .00 1033.21TOTALS 1033.21 .00 1033.21----------------------------------------------------------------------------------------------------------------------------------------------------------------

• Financial Summary page provides summarized check and invoice information• If provider had claims for Acute and Long Term Care recipients, LTC totals would

be shown on separate line below Acute totals• If all claims in process or denied, Financial Summary page will indicate “No Active

Invoices”• Gross Amount and Net Amount (Check Amount) will be equal unless TYPE

column shows “CR” indicating provider has credit

Remittance Advice


SAMPLE REMITTANCE ADVICE – PAID NON-FACILITY CLAIMS

REPORT ID: FI04W400 HAWAII DHS MED-QUEST DIVISION PMMIS PAGE: 9PROGRAM ID: FI04L400 NON-FACILITY REMITTANCE ADVICE - ACUTE RUN:

11/28/98001549 PAID CLAIMS - INVOICE DATE: 11/28/98

BILLING PROVIDER: 654321 01 H0LLIDAY, DOC INVOICE NUMBER: A9800000000001SERVICE PROVIDER: 654321 01 HOLLIDAY, DOC CHECK NUMBER: 48746

PAYMENT DATE: 12/01/98

TAX ID: 999999999FORM TYPE: FORM 1500

HI ID NAME CRN SERVICE CD/ DATES OF BILLED AMOUNT ALLOWEDRECIPIENT PATIENT ACCOUNT NUMBER STATUS DATE MODIFIER SERVICE BILLED UNITS UNITS----------------------------------------------------------------------------------------------------------------------------------------------------------------------A12007007 BOND, JAMES 98310000100801 99223 10/09/98 150.00 1.00 29.00 ALLOWED AMOUNT (*) A12007007 007 11/26/98 1.00 -----------

29.00 NET PAID AMOUNTPRICE EXPL: SUB *MCC----------------------------------------------------------------------------------------------------------------------------------------------------------------A12007007 BOND, JAMES 98310000103701 99233 10/10/98 400.00 5.00 72.00 ALLOWED AMOUNT (*) A12007007 007 11/26/98 10/14/98 5.00 -----------

72.00 NET PAID AMOUNTPRICE EXPL: SUB *MCC----------------------------------------------------------------------------------------------------------------------------------------------------------------A61743893 HOLMES, SHERLOCK 98310000100801 99233 10/09/98 300.00 3.00 222.00 ALLOWED AMOUNT (*) A61743893 12714-350493 11/26/98 10/11/98 3.00 -----------

222.00 NET PAID AMOUNT PRICE EXPL: MAC *AHA----------------------------------------------------------------------------------------------------------------------------------------------------------------A21742813 KURIYAKIN, ILYA 98310000100801 90828 10/24/98 800.00 5.00 680.00 ALLOWED AMOUNT (*) A21742813 12224-489133 11/26/98 10/28/98 5.00 270.00- OTHER INSURANCE

-----------410.00 NET PAID AMOUNT

PRICE EXPL: SUB MAC *AHA----------------------------------------------------------------------------------------------------------------------------------------------------------------A21742813 PEELE, EMMA 98310000100801 99233 10/24/98 290.00 3.00 146.00 ALLOWED AMOUNT (*) A21742813 12714-350493 11/26/98 10/26/98 3.00 -----------

146.00 NET PAID AMOUNT PRICE EXPL: SUB *MCC *MCD----------------------------------------------------------------------------------------------------------------------------------------------------------------

NUMBER OF CLAIMS: 5TOTAL BILLED AMOUNT: 1,940.00TOTAL REMIT AMOUNT: 879.00

SAMPLE REMITTANCE ADVICE – DENIED NON-FACILITY CLAIMS

• PRICE EXPL(anation) codes listed on Processing Notes page• Asterisk (*) before PRICE EXPL code shows how Allowed Amount

was determined (e.g., MCC = Medicare Coinsurance, MCD = MedicareDeductible, AHA = MQD Allowed)

• Allowed Amount listed first, followed by any deductions (e.g., otherinsurance)

• Last page of Paid Claims section lists totals

Remittance Advice



11/28/98DENIED CLAIMS

BILLING PROVIDER: 654321 01 HOLLIDAY, DOCSERVICE PROVIDER: 654321 01 HOLLIDAY, DOC


SERVICE CD/ DATES OF HI ID RECIPIENT NAME PATIENT ACCOUNT NBR CRN MODIFIER SERVICE BILLED AMOUNT BILLEDUNITS ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- A15116678 A15116678 BONNEY, WILLIAM BTK96007 98310000102301 90828 10/22/98 160.00 1.00 REASON CDS: H077.2 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- A12003210 A12003210 CLANCY, IKE 96-007L 98310000100801 99245 10/17/98 96.00 1.00 REASON CDS: H094.1 L017.1 L019.1 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- A21110770 A21110770 EARP, WYATT XYX96089 9831000020170 99233 10/02/98 255.00 3.00 REASON CDS: L017.1 10/04/98 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- A12345678 A12345678 JANE, CALAMITY ABC96027 98310000100801 99223 10/12/98 150.00 1.00 REASON CDS: L019.1 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- A12345678 A12345678 JANE, CALAMITY ABC96027 98310000100802 99233 10/13/98 85.00 1.00 REASON CDS: L019.1 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- A12007007 A12007007 BOND, JAMES XYX96033 98310000100801 99233 10/15/98 85.00 1.00 REASON CDS: H094.1 -------------------------------------------------------------------------------------------------------------------------------------------------------------------- NUMBER OF CLAIMS: 6 TOTAL BILLED AMOUNT: 831.00

• Explanations of denial REASON CDS listed onProcessing Notes page

• Multiple denial reasons can be reported• Last page of Denied Claims section lists totals

Remittance Advice


SAMPLE REMITTANCE ADVICE – ADJUSTED NON-FACILITY CLAIMS


11/28/98001549 ADJUSTED CLAIMS - INVOICE DATE: 11/28/98




HI ID NAME CRN SERVICE CD/ DATES OF BILLED AMOUNT ALLOWEDRECIPIENT PATIENT ACCOUNT NUMBER STATUS DATE MODIFIER SERVICE BILLED UNITS UNITS----------------------------------------------------------------------------------------------------------------------------------------------------------------------A61743893 HOLMES, SHERLOCK 98310000100801 99233 10/09/98 300.00 3.00 222.00 ALLOWED AMOUNT (*) A61743893 12714-350493 11/26/98 10/11/98 3.00 148.00- PREVIOUSLY PAID

-----------74.00 NET PAID AMOUNT

PRICE EXPL: MAC *AHA----------------------------------------------------------------------------------------------------------------------------------------------------------------A21742813 KURIYAKIN, ILYA 98310000100801 90828 10/24/98 800.00 5.00 680.00 ALLOWED AMOUNT (*) A21742813 12224-489133 11/26/98 10/28/98 5.00 544.00- PREVIOUSLY PAID

-----------136.00 NET PAID AMOUNT

PRICE EXPL: SUB MAC *AHA----------------------------------------------------------------------------------------------------------------------------------------------------------------A21742813 PEELE, EMMA 98310000100801 99233 10/24/98 290.00 3.00 146.00 ALLOWED AMOUNT (*) A21742813 12714-350493 11/26/98 10/26/98 3.00 190.00- PREVIOUSLY PAID

-----------44.00- NET PAID AMOUNT

PRICE EXPL: SUB *MCC *MCD----------------------------------------------------------------------------------------------------------------------------------------------------------------

NUMBER OF CLAIMS: 3TOTAL BILLED AMOUNT: 1,390.00TOTAL REMIT AMOUNT: 166.00

• New Allowed Amount listed first• Previously Paid Amount “backed out” as negative• Net Paid Amount shows difference• Net Paid Amount will be negative if adjusted Allowed

Amount is less than original Allowed Amount• Last page of Adjusted Claims section lists totals

Remittance Advice


SAMPLE REMITTANCE ADVICE – VOIDED NON-FACILITY CLAIMS


11/28/98VOIDED CLAIMS - INVOICE DATE: 11/28/98




HI ID NAME CRN SERVICE CD/ DATES OF BILLED AMOUNT ALLOWEDRECIPIENT PATIENT ACCOUNT NUMBER STATUS DATE MODIFIER SERVICE BILLED UNITS UNITS----------------------------------------------------------------------------------------------------------------------------------------------------------------------A12007007 BOND, JAMES 98310000100801 99223 10/09/98 150.00 1.00 29.00- ALLOWED AMOUNT (*) A12007007 007 11/26/98 1.00 -----------

29.00- NET PAID AMOUNTPRICE EXPL: SUB *MCC----------------------------------------------------------------------------------------------------------------------------------------------------------------A12007007 BOND, JAMES 98310000103701 99233 10/10/98 400.00 5.00 72.00- ALLOWED AMOUNT (*) A12007007 007 11/26/98 10/14/98 5.00 -----------

72.00- NET PAID AMOUNTPRICE EXPL: SUB *MCC----------------------------------------------------------------------------------------------------------------------------------------------------------------

NUMBER OF CLAIMS: 2TOTAL BILLED AMOUNT: 550.00TOTAL RECOUPED AMOUNT: 101.00

• New Allowed Amount listed first as a negative• Any previous deductions would be “backed

out” as positive• Net Paid Amount shows amount recouped• Last page of Voided Claims section lists totals

Remittance Advice


SAMPLE REMITTANCE ADVICE –NON-FACILITY CLAIMS IN PROCESS


11/28/98CLAIMS IN PROCESS

BILLING PROVIDER: 654321 01 H0LLIDAY, DOCSERVICE PROVIDER: 654321 01 H0LLIDAY, DOC


SERVICE CD/ DATES OF HI ID RECIPIENT NAME PATIENT ACCOUNT NBR CRN MODIFIER SERVICE BILLED AMOUNT BILLEDUNITS ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- A15116678 A15116678 BONNEY, WILLIAM BTK96007 98310000102301 90828 10/22/98 160.00 1.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- A12003210 A12003210 CLANCY, IKE 96-007L 98310000100801 99245 10/17/98 96.00 1.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- A21110770 A21110770 EARP, WYATT XYX96089 9831000020170 99233 10/02/98 255.00 3.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- A12345678 A12345678 JANE, CALAMITY ABC96027 98310000100801 99223 10/12/98 150.00 1.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- A12345678 A12345678 JANE, CALAMITY ABC96027 98310000100802 99233 10/13/98 85.00 1.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- A12007007 A12007007 BOND, JAMES XYX96033 98310000100801 99233 10/15/98 85.00 1.00 -------------------------------------------------------------------------------------------------------------------------------------------------------------------- NUMBER OF CLAIMS: 6 TOTAL BILLED AMOUNT: 831.00

• There is no STATUS DATE field because claims havenot reached adjudicated status of Paid or Denied

• Section includes claims reported as in process inprevious Remittances

• Last page of Claims In Process section lists totals

Remittance Advice


SAMPLE REMITTANCE ADVICE – PROCESSING NOTES

REPORT ID: FI04W400 HAWAII DHS MED-QUEST DIVISION PMMIS PAGE: 15PROGRAM ID: FI04L400 REMITTANCE ADVICE - PROCESSING NOTES RUN:

11/28/98

BILLING PROVIDER: 654321 01 H0LLIDAY, DOC


NOTE TYPE DESCRIPTION------ ---- -----------------------------------------------------------------------------------------------------------------------------------------

** PLEASE CALL PROVIDER SERVICES FOR FURTHER EXPLANATION OF ANY DESCRIPTION **

** PROVIDER SERVICES MAY BE REACHED AT (808) 952-5570 or 1-800-235-4378.

AHA P MQD ALLOWED AMOUNT

H077.2 R SERVICE PROVIDER LOCATION CODE IS INVALID

H094.1 R PRIMARY DIAGNOSIS CODE FIELD IS NOT ON FILE

H140.3 R PRIMARY DIAGNOSIS CODE NOT COVERED FOR CONTRACT TYPE

L017.1 R PLACE OF SERVICE CODE IS MISSING

L019.1 R DIAGNOSIS REFERENCE CODE 31 IS MISSING

L067.1 R RECIPIENT HAS PART B; MEDICARE DATA MUST BE INDICATED, IS MISSING

MAX M MAXIMUM ALLOWED CHARGE/CAPPED FEE

MCC T MEDICARE COINSURANCE

MCD T MEDICARE DEDUCTIBLE

PDM M PER DIEM

SUB M SUBMITTED AMOUNT FROM CLAIM

NOTE TYPES: M = PRICING METHOD, P = PRICING TYPE, R = REASON CODE, T = IER, X = MODIFIER

• Remittance Advice Processing Notes is last section inpackage

• Alphabetical listing of processing note codedescriptions (denial reasons, pricing methods, etc.)

• Each code listed only once even if applicable to

Remittance Advice


SAMPLE REMITTANCE ADVICE – PAID FACILITY INPATIENT CLAIMS

REPORT ID: FI04W400 HAWAII DHS MED-QUEST DIVISION PMMIS PAGE: 3PROGRAM ID: FI04L400 FACILITY REMITTANCE ADVICE - ACUTE RUN:


BILLING PROVIDER: 654321 01 ARIZONA HOSPITAL INVOICE NUMBER: A9800000000001SERVICE PROVIDER: 654321 01 ARIZONA HOSPITAL CHECK NUMBER: 48746


TAX ID: 999999999FORM TYPE: INPATIENT

HI ID NAME CRN DATES OF BILLED AMOUNT ALLOWEDRECIPIENT PATIENT ACCOUNT NUMBER STATUS DATE SERVICE BILLED UNITS UNITS----------------------------------------------------------------------------------------------------------------------------------------------------------------------A12345678 OAKLEY, ANNIE 983100001001 10/20/98 760.00 1.00 760.00 ALLOWED AMOUNT (*)A12345678 O011617768-1 11/26/98 10/21/98 1.00 ----------

760.00 NET PAIDAMOUNT PRICE EXPL: PDM *AHA----------------------------------------------------------------------------------------------------------------------------------------------------------------A87654321 JANE, CALAMITY 983100002002 10/25/98 1,520.00 2.00 1,520.00 ALLOWED AMOUNT (*)A87654321 J4176027943-1 11/26/98 10/27/98 2.00 ----------

1,520.00 NET PAIDAMOUNT PRICE EXPL: PDM *AHA----------------------------------------------------------------------------------------------------------------------------------------------------------------A18273645 EARP, WYATT 983100003003 10/19/98 760.00 3.00 2,280.00 ALLOWED AMOUNT (*)A18273645 E0116543257-2 11/26/98 10/22/98 3.00 ----------

2,280.00 NET PAIDAMOUNT PRICE EXPL: PDM *AHA----------------------------------------------------------------------------------------------------------------------------------------------------------------A11223344 YOUNGER, COLE 983100004004 10/21/98 2,280.00 1.00 760.00 ALLOWED AMOUNT (*)A11223344 Y0227188796-1 11/26/98 10/22/98 3.00 ----------

760.00 NET PAIDAMOUNT PRICE EXPL: PDM *AHA----------------------------------------------------------------------------------------------------------------------------------------------------------------A43218765 CRAWFORD, KATY 983100005005 10/23/98 6,080.00 8.00 6,080.00 ALLOWED AMOUNT (*)A43218765 C5522613008-1 11/26/98 10/31/98 8.00 ----------

6,080.00 NET PAIDAMOUNT PRICE EXPL: PDM *AHA----------------------------------------------------------------------------------------------------------------------------------------------------------------A18273645 JAMES, JESSE 983100006006 10/28/98 1,520.00 2.00 1,520.00 ALLOWED AMOUNT (*)A18273645 J7158700699-1 11/26/98 10/30/98 2.00 ----------

1,520.00 NET PAIDAMOUNT PRICE EXPL: PDM *AHA

Remittance Advice


SAMPLE REMITTANCE ADVICE – PAID FACILITY OUTPATIENT CLAIMS





TAX ID: 999999999FORM TYPE: OUTPATIENT

HI ID NAME CRN DATES OF BILLED AMOUNT ALLOWEDRECIPIENT PATIENT ACCOUNT NUMBER STATUS DATE SERVICE BILLED UNITS UNITS----------------------------------------------------------------------------------------------------------------------------------------------------------------------A12345678 OAKLEY, ANNIE 983150002002 10/20/98 652.00 274.49 ALLOWED AMOUNT (*)A12345678 O011617768-1 11/26/98 10/20/98 ----------

274.49 NET PAIDAMOUNT PRICE EXPL: (CCO - .4210) *AHA----------------------------------------------------------------------------------------------------------------------------------------------------------------A87654321 JANE, CALAMITY 983150008008 10/25/98 450.00 189.45 ALLOWED AMOUNT (*)A87654321 J4176027943-1 11/26/98 10/25/98 ----------

189.45 NET PAIDAMOUNTPRICE EXPL: (CCO - .4210) *AHA----------------------------------------------------------------------------------------------------------------------------------------------------------------A18273645 EARP, WYATT 983150007007 10/19/98 750.00 315.75 ALLOWED AMOUNT (*)A18273645 E0116543257-2 11/26/98 10/19/98 ----------

315.75 NET PAIDAMOUNTPRICE EXPL: (CCO - .4210) *AHA----------------------------------------------------------------------------------------------------------------------------------------------------------------A11223344 YOUNGER, COLE 983150009009 10/21/98 980.00 412.58 ALLOWED AMOUNT (*)A11223344 Y0227188796-1 11/26/98 10/21/98 ----------

412.58 NET PAIDAMOUNTPRICE EXPL: (CCO - .4210) *AHA----------------------------------------------------------------------------------------------------------------------------------------------------------------

NUMBER OF CLAIMS: 10TOTAL BILLED AMOUNT: 15,752.00TOTAL REMIT AMOUNT: 14,112.27

• PRICE EXPL(anation) codes listed onProcessing Notes page

• Asterisk (*) before PRICE EXPL code showshow Allowed Amount was determined (e.g.,CCO = Hospital-specific Outpatient Cost-To-Charge Ratio, AHA = MQD Allowed)

• Last page of Paid Claims section lists totalsfor inpatient and outpatient claims

Remittance Advice


SAMPLE REMITTANCE ADVICE – DENIED FACILITY CLAIMS


11/28/98001549 DENIED CLAIMS

BILLING PROVIDER: 654321 01 ARIZONA HOSPITALSERVICE PROVIDER: 654321 01 ARIZONA HOSPITAL


AHCCCS ID RECIPIENT NAME PATIENT ACCOUNT NBR CRN DATES OF SERVICE BILLED AMOUNT BILLEDUNITS ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- A17520033 A17520033 DOS PASSOS, JOHN 147A321 983100050001 10/24/98 10/26/98 1,520.00 2.00 REASON CDS: H154.3 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- A17650082 A17650082 HAWTHORNE, NATHANIEL 148C123 983100010113 10/29/98 10/30/98 760.00 1.00 REASON CDS: H140.3 H141.3 H142.3 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- A17050080 A17050080 HEMINGWAY, ERNEST 168B456 983100010212 10/01/98 10/02/98 760.00 1.00 REASON CDS: L027.1 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- A17030074 A17030074 IRVING, WASHINGTON 148D789 983100010212 10/23/98 10/26/98 2,280.00 3.00 REASON CDS: L027.1 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- 525465421 525465421 STEIN, GERTRUDE 150L654 983100777763 10/04/98 10/06/98 1,520.00 2.00 REASON CDS: H082.3 ------------------------------------------------------------------------------------------------------------------------------------------------------------------- NUMBER OF CLAIMS: 5TOTAL BILLED AMOUNT: 6,840.00

• Explanations of denial REASON CDS listed onProcessing Notes page

• Multiple denial reasons can be reported• Last page of Denied Claims section lists totals

for inpatient and outpatient claims

Remittance Advice


SAMPLE REMITTANCE ADVICE – ADJUSTED FACILITY CLAIMS


11/28/98ADJUSTED CLAIMS - INVOICE DATE: 11/28/98




AHCCCS ID NAME CRN DATES OF BILLED AMOUNT ALLOWEDRECIPIENT PATIENT ACCOUNT NUMBER STATUS DATE SERVICE BILLED UNITS UNITS----------------------------------------------------------------------------------------------------------------------------------------------------------------------A12345678 OAKLEY, ANNIE 983100001001 10/20/98 2,280.00 3.00 2,280.00 ALLOWED AMOUNT (*)A12345678 O011617768-1 11/26/98 10/23/98 3.00 760.00- PREVIOUSLYPAID

-----------1,520.00 NET PAID

AMOUNT PRICE EXPL: PDM *AHA----------------------------------------------------------------------------------------------------------------------------------------------------------------A87654321 JANE, CALAMITY 983100001001 10/26/98 2,280.00 2.00 1,520.00 ALLOWED AMOUNT (*)A87654321 J4176027943-1 11/26/98 10/29/98 3.00 2,280.00- PREVIOUSLYPAID

-----------760.00- NET PAID

AMOUNT PRICE EXPL: PDM *AHA---------------------------------------------------------------------------------------------------------------------------------------------------------------- NUMBER OF CLAIMS: 2TOTAL BILLED AMOUNT: 4,560.00TOTAL REMIT AMOUNT: 760.00

• New Allowed Amount listed first• Previously Paid Amount “backed out” as negative• Net Paid Amount shows difference• Net Paid Amount will be negative if adjusted Allowed

Amount is less than original Allowed Amount• Last page of Adjusted Claims section lists totals for

inpatient and outpatient claims

Remittance Advice


SAMPLE REMITTANCE ADVICE – VOIDED FACILITY CLAIMS


11/28/98VOIDED CLAIMS - INVOICE DATE: 11/28/98




AHCCCS ID NAME CRN DATES OF BILLED AMOUNT ALLOWEDRECIPIENT PATIENT ACCOUNT NUMBER STATUS DATE SERVICE BILLED UNITS UNITS----------------------------------------------------------------------------------------------------------------------------------------------------------------------A12345678 OAKLEY, ANNIE 983100001001 10/20/98 760.00 1.00 760.00- ALLOWED AMOUNT (*)A12345678 O011617768-1 11/26/98 10/21/98 1.00 ----------

760.00- NET PAIDAMOUNT PRICE EXPL: PDM *AHA----------------------------------------------------------------------------------------------------------------------------------------------------------------A87654321 JANE, CALAMITY 983100002002 10/25/98 1,520.00 2.00 1,520.00- ALLOWED AMOUNT (*)A87654321 J4176027943-1 11/26/98 10/27/98 2.00 ----------

1,520.00- NET PAIDAMOUNT PRICE EXPL: PDM *AHA----------------------------------------------------------------------------------------------------------------------------------------------------------------

NUMBER OF CLAIMS: 2TOTAL BILLED AMOUNT: 2,280.00TOTAL RECOUPED AMOUNT: 2,280.00

• New Allowed Amount listed first as a negative• Any previous deductions would be “backed

out” as positive• Net Paid Amount shows amount recouped• Last page of Voided Claims section lists totals

for inpatient and outpatient claims

Remittance Advice


SAMPLE REMITTANCE ADVICE –FACILITY CLAIMS IN PROCESS


11/28/98CLAIMS IN PROCESS

BILLING PROVIDER: 654321 01 ARIZONA HOSPITALSERVICE PROVIDER: 654321 01 ARIZONA HOSPITAL


AHCCCS ID RECIPIENT NAME PATIENT ACCOUNT NBR CRN DATES OF SERVICE BILLED AMOUNT BILLEDUNITS ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- A17520033 A17520033 COBB, TYRUS RAYMOND 147A321 983100050001 10/24/98 10/26/98 1,520.00 2.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- A17650082 A17650082 GEHRIG, LOUIS 148C123 983100010113 10/29/98 10/30/98 760.00 1.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- A17050080 A17050080 RUTH, GEORGE HERMAN 168B456 983100010212 10/01/98 10/02/98 760.00 1.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- A17030074 A17030074 WILSON, HACK 148D789 983100010212 10/23/98 10/26/98 2,280.00 3.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- NUMBER OF CLAIMS: 4TOTAL BILLED AMOUNT: 5,320.00

• There is no STATUS DATE field because claimshave not reached adjudicated status of Paid orDenied

• Section includes claims reported as in process inprevious Remittances

• Last page of Claims In Process section lists totalsfor inpatient and outpatient claims

P:\HAPA Claims\Information\Revised Provider Manual\Revised Provider Manual v.4\Appendix 1 General - Final\A49Sample Medicaid ID Cardv.4.doc v5/30/02

PROVIDER MANUAL: Pages A1 – A62 Sample of Medicaid ID Card Page A49

ALOHA J. SMITHDOB: 01/01/19920009999999

Back of card:

State of HawaiiDepartment of Human Services

Med-QUEST DivisionTHIS CARD DOES NOT GUARANTEE ELIGIBITY

Attention Providers:• Eligibility information may be obtained by calling: (800) 882-4608• To report fraud, please call the Fraud Hotline at: (808) 587-8444• You are responsible for verifying recipient eligibility and proper identification of

the card holderAttention Recipients:

• Please carry this card with you at all times• Unauthorized use of this card is a violation of federal and state law and may

result in criminal prosecution.• If you have any questions, please call the Enrollment Call Center at:

(808) 524-3370 or toll-free at (800) 316-8005• Keep this card even if you get a notice saying that you are no longer eligible. If

you get Medicaid in the future, you will use the same card.

State of HawaiiDepartment of Human ServicesMedicaid Identification Card

PROVIDER MANUAL: APPENDIX 1 Pages A1 to A62GENERALServices and Items Not Covered by Pages A50 of A54the Hawaii Medicaid Program

SERVICES AND ITEMSNOT COVERED BY THE HAWAII MEDICAID PROGRAM

General

• Services, procedures, drugs, devices, equipment and treatment that are experimental,investigational, or of generally unproven benefit, excluded by federal regulations or staterules and/or not medically necessary.

• All medical, surgical and/or psychiatric services, drugs (including hormones needed forchanging the sex of an individual), equipment/devices and supplies related to genderreassignment.

• All medical and surgical procedures, therapies, supplies, drug equipment for the treatment ofsexual dysfunction.

Medical and Surgical Services

• Stand-by services by stand-by physicians, telephone consultations, telephone calls, writing ofprescriptions and stat charges.

• Psychiatric care and treatment for sex and marriage problems, weight control, employmentcounseling, primal therapy, long term character analysis, marathon group therapy and/orconsortium services.

• Long term psychiatric institutional treatment.

• Routine foot care; treatment of flat feet.

• Physical exams for employment when the patient is self-employed or as a requirement forcontinuing employment (i.e. truck and taxi drivers’ licensing, other physical exams as arequirement for continuing employment by the State or Federal Government or by privatebusiness.

• Physical exams, psychological evaluations and/or immunizations as a requirement for Hawaiior other states’ drivers’ licenses or for the purpose of securing life and other insurancepolicies or plans.

• Physical exams and/or immunizations for travel—domestic or foreign.

• In vitro fertilization, reversal of sterilization, artificial insemination, sperm bankingprocedures and all drugs and devices to treat infertility or enhance fertilization.


Medical and Surgical Services (Continued)

• Cosmetic surgery or treatment to improve appearance and not bodily function, including butnot limited to cosmetic rhinoplasties, reconstructive/plastic surgery such as face lifts toimprove appearance and not bodily function, lyposuction, paniculectomies, and other bodysculpturing procedures, piercing of ears and other body areas, electrolysis, hairtransplantation or removal, tattooing or removal of tattoos.

• Cosmetic, reconstructive, or plastic surgery procedures performed primarily forpsychological reasons or as a result of the aging process.

• Augmentation mammoplasties except following medically indicated mastectomies forcarcinoma, precancerous conditions, or extensive fibrosis or traumatic amputation.

• Reduction mammoplasties unless there is medical documentation of intractable pain notamenable to other forms of treatment as a result of large pendulous breasts.

• Jejuno-ileal by-pass procedures for morbid obesity.

• Tuberculosis services when provided free to the general public.

• Hansen’s disease treatment or follow-up.

• Treatment of persons confined to public institutions.

• Orthoptic training

• Ambulatory Blood Pressure Monitoring

Drugs

• Drugs not approved by the Food and Drug Administration (FDA).

• Drugs from manufacturers that do not have a current rebate agreement with the Health CareFinancing Administration (HFCA) also called the Centers for Medicare and MedicaidServices (CMS).

• Drugs determined to be “less than effective” by the federal government. (Drug EfficacyStudies Implementation? DESI 5 and 6).


Equipment, Supplies, and Devices

• Equipment, supplies and devices not primarily medical in nature.

• Penile and testicular prostheses and related services

• Personal care items including but not limited to shampoos, toothpaste, toothbrushes, mouthwashes, denture cleansers and adhesives, shoes slippers, clothing, laundry services, baby oiland powder, sanitary napkins, soaps, lip balm, band aids.

• Non-medical items including but not limited to books, telephone, beepers, radios, linens,clothing, television sets, computers, air conditioners, air purifiers, fans.

• Educational supplies

• Standard household items including but not limited to cooking utensils, blenders andfurniture.

• Beds, including, but not limited to lounge beds, bead beds, water beds, day beds; overbedtables, bed lifters, bed boards, be side rails, if not an integral part of a hospital bed.

• Food, health foods and food supplements.

• Tinted lenses except for aphakia

• Contact lenses for cosmetic purposes; bifocal contact lenses.

• Oversized lenses

• Blended or progressive bifocal lenses.

• Tinted or absorptive lenses (except for aphakia, albinism, glaucoma, medical photophobia)

• Trifocal lenses (except as a specific job requirement)

• Spare glasses

• In the ear hearing aids, hearing aid glasses


Dental Services

• All non-emergency dental services for recipients over 20 years of age

• For recipients under 21 years of age,

1. Orthodontic services except following repair of a cleft palate or other severedevelopmental defect or injury in a child for which the functions of speech, swallowingor chewing cannot be restored

2. Fixed bridge work

3. Plaque control and nutritional counseling

4. Gold crowns and gold inlays

5. Procedures, appliances or restorations solely for cosmetic purposes

Miscellaneous Services and Items

• Acupuncture

• Biofeedback

• Chiropractic services

• Christian Science services

• Faith healing

• Hypnosis

• Massage treatment by masseurs

• Naturopathic services

• Physician assistant services

• Certified registered nurse anesthetist (CRNA) services

• Obesity treatment such as weight control classes, weight loss programs and speciallyprepared diets

• Swimming lessons, summer camp, gym membership, smoking cessation classes.


Miscellaneous Services and Items

• Topical application of oxygen

• HCPCS codes in the range C0001-C9999—Temporary Codes for Use with only withMedicare Outpatient PPS.

• HCPCS codes in the range S0001-S9999—codes developed by Blue Cross/Blue Shield andother commercial payers to report drugs, services, and supplies and not for use to billservices paid under Medicare.

PROVIDER MANUAL: APPENDIX 1 Page A1 to A62GENERALServices/Items That Require Authorization Pages A55 of A62

SERVICES/ITEMSTHAT REQUIRE AUTHORIZATION

ITEM/SERVICE FORM COMMENTS

TRANSPORTATIONAir Transportation--out-of-state 1144Air Transportation--inter-island 208HandiCab and HandiVan 1160 Forms are obtained by the patient from the

patient’s DHS workerTaxi 1135 Forms are obtained by the patient from the

patient’s DHS worker

MEDICAL SUPPLIESAll medical supplies with charges over$50.00 per month (except diabeticsupplies)

1144

DURABLE MEDICAL EQUIPMENT/PROSTHETIC DEVICES AND ORTHOTIC DEVICES(DMEPO)

All purchases, rentals, repairs,maintenance of DMEPO with chargesover $50.00 per month per item

1144

ENTERAL/PARENTERAL SUPPLIES/EQUIPMENTAll enteral formula/parenteral nutritionand supplies (gravity bags, syringes,tubes, etc.)

1144 Providers that are NOT home infusionproviders should send 1144 forms to theMedicaid Fiscal Agent, ACS; Providers thatare home infusion providers should send 1144forms to Pharmacy Fiscal Agent,ACS/Consultec

HOME INFUSION SERVICESAll home infusion services 1144 Send 1144 forms to ACS Consultec

HOME HEALTH AGENCY SERVICESSkilled Nursing Visits 1144Home Health Aide Visits 1144Occupational Therapy 1144Physical Therapy 1144Speech Therapy 1144



DRUGSCertain single source drugs; multiplesource drugs with generic equivalentsthat have federal upper limits

1144 Send 1144 forms to Consultec; for a completelisting of drugs that require authorization, seeAppendix 6.

VISION, SPEECH AND HEARING ITEMS AND SERVICESTrifocal lenses and associated services 1144Contact lenses and associated services 1144Low vision aids 1144Telescopic/compound lens systems 1144Prosthetic eyes and associated servicesand supplies

1144

Balance lenses; slab off prism lenses;prisms; press-on lenses (Fresnell prism);special base curve lenses

1144

Tinting of lenses 1144Anti-reflective coating of lenses 1144U-V lenses 1144Scratch resistant coating of lenses 1144Occluder lenses 1144Not otherwise classified vision services 1144Augmentative CommunicationDevices— purchase, rental,maintenance, repairs, modifications

1144

Speech, language, voice, communicationevaluation and treatment

1144

Aural rehabilitation following coclearimplant

1144

Swallowing and oral functioningevaluation and treatment

1144

Hearing aids—purchase, rental,maintenance, repairs, modifications,insurance

1144

DENTAL ITEMS AND SERVICES

Medicaid recipients 21 years of age and older receive only EMERGENCY DENTAL SERVICES; thefollowing dental services require authorization ONLY when provided to Medicaid recipients under 21years of age



DENTAL ITEMS AND SERVICES (Continued)Dental treatment done in inpatient oroutpatient hospital under generalanesthesia

1144

Tomographic Survey 1144Topical application of fluoride forMedicaid recipients over 18 years of age

1144

Crowns (except prefabricated stainlesssteel crowns)

1144

Unspecified oral surgery, orthodonticprocedures, adjunctive procedures

1144

General anesthesia 1144

SURGERY

Generally in CPT Code Range 10000-19999Removal/destruction of benign skinlesions by paring, cutting, shaving,excision, laser, etc.

1144 Flat, juvenile warts, fibrocutaneous tags,leukoplakia, actinic or senile keratoses,keratocanthomas, facial nevi requireauthorization. Authorization is also requiredfor removal of benign lesions in CPT coderanges other than 10000-19999. Molluscumcontagiosum, plantar, palmar and finger tipwarts and venereal warts do not requireauthorization.

Tattooing to correct color defects of skin 1144Subcutaneous injection of “filling”material (collagen)

1144

Application of xenograft 1144Dermabrasion, salabrasion, andchemical peels

1144

Blepharoplasty 1144Rhytidectomy 1144Excision of excessive skin andsubcutaneous tissue

1144

Grafts for facial nerve paralysis 1144Epilation by electrolysis 1144Mastectomy for gynecomastia,mastopexy, reduction and augmentationmammaplasties

1144



Generally in CPT Code Range 10000-19999 (Continued)Insertion of breast prosthesis 1144Breast, nipple/areola reconstruction 1144

Generally in CPT Code Range 20000-29999Cartilage graft (nasal septum), fascialata graft

1144

Non-operative ultrasound to aid bonehealing

1144

Impression and custom preparation oforal or facial prostheses and relatedservices

1144

Genioplasty 1144Reconstruction of face and associatedservices (craniofacial, orbital andmaxillofacial)

1144

Costotransversectomy 1144Ostectomy of sternum 1144Reconstructive repair of pectusexcavatum

1144

Pollicization of a digit 1144Transfer of a finger to another positionOsteotomy of first metatarsal withautograft

1144

Reconstruction of toes 1144Temporomandibular joint arthroscopy 1144

Generally in CPT Code Range 30000-49999Rhinophyma-excision or surgicalplaning

1144

Rhinectomy and rhinoplasty 1144Septoplasty, septal/intranasaldermatoplasty, repair of nasal septalperformation and other procedures onthe nose

1144

Larngoscopy with stroboscopy 1144Gingivoplasty, alveoloplasty, otherunspecified surgery on dentoalveolarstructures

1144

Palatopharngoplasty,uvulopalatopharyngoplasty

1144



Generally in CPT Code Range 30000-49999 (Continued)Gastric restrictive procedures with orwithout gastric bypass

1144

Repair of reducible, non-incarceratedincisional, ventral, epigastric, umbilicalhernias

1144

Generally in CPT Code Range 50000-59999Lithotripsy 1144Revision of urinary-cutaneousanastomosis with repair of fascial defectand hernia

1144

Cystourethroscopy with lithotripsy 1144Circumcision, except newborn 1144Cavernosometry, injection of corporacavernosa

1144

Removal/repair of penile prosthesis 1144Plastic operation on penis for injuryEpididymovasostomyVasectomy 1146 Must meet all consent and notification

requirementsVasovasostomy, vasovasorrhaphy 1144Tubal ligation ( any method includingfulguration, occlusion, transection)

1146 Must meet all consent and notificationrequirements

Clitoroplasty; vaginoplasty 1144Hysterectomy 1145 Must meet all consent and notification

requirementsPelvic enteration for gynecologicmalignancy with hysterectomy

1145 Must meet all consent and notificationrequirements

Uterine suspension 1144

Generally in CPT Code Range 60000-69999Craniotomy for lobotomy, includingcingulotomy

1144

Stereotactic radiosurgery (particle beam,gamma ray or linear accelerator)

1144

Neurostimulator and surgical servicesassociated with implantation,replacement, revision, removal, etc.

1144



Generally in CPT Code Range 60000-69999 (Continued)Subarachnoid catheter and surgicalservices associated with insertion,replacement, removal, etc.

1144

Sympathectomy 1144Multiple punctures of anterior cornea 1144Keratomileusis 1144Exchange of intraocular lense 1144Strabismus surgery 1144Unlisted procedures on ocular muscles 1144Blepharoptosis repair, correction of lidretraction

1144

Otoplasty for protruding ear 1144Implantation or replacement ofelectronic bone conduction hearingdevice in temporal bone

1144

Cochlear device implantation andrelated services

PODIATRIC SERVICESOutpatient/Inpatient services over than$100.00

1144

RADIOLOGYMagnetic Resonance Imagining (MRI) 1144Magnetic resonance spectroscopy,magnetic resonance angiography

1144

Complex dynamic pharyngeal andspeech evaluation

1144

Hysterosonography 1144Hyperthermia 1144Positron emission tomography (PET)imaging

1144

LABORATORYAutologous blood or component,collection processing and storage;predeposited

1144

Bone marrow, modification or treatmentto eliminate cells (e.g. T-cells,metastatic carcinoma)

1144



LABORATORY (Continued)Tissue culture for non-neoplastic andneoplastic disorders;

1144

Chromosome analysis 1144Cryopreservation, freezing and storageof cells, each cell line

1144

Thawing and epansion of frozen cells 1144Molecular cytogentics 1144

PSYCHIATRIC/PSYCHOLOGIC SERVICESPsychotherapy (both individual andgroup)

1018 For outpatient psychotherapy

Psychoanalysis 1018Electrconvulsive therapy 1144Psychologic/Neuropsychologic testing 1144Psychiatric Inpatient Admission 1144Clozapine Medical Management 1144

NEUROLOGY AND NEUROMUSCULAR SERVICESSleep studies includingpolysomnography and all night sleepelectroencephalogram (EEG)

1144

Muscle testing , manual 1144Range of Motion measurements 1144Monitoring for identification andlateralization of cerebral seizure focus

1144

Functional cortical and subcorticalmapping to provoke seizures or identifyvital brain structures

1144

Electronic analysis of complex cranialnerve Neurostimulator pulsegenerator/transmitter

1144

PHYSICAL THERAPY AND OCCUPATIONAL THERAPYPhysical therapy re-evaluation 1144Occupational therapy re-evaluation 1144



PHYSICAL THERAPY AND OCCUPATIONAL THERAPY (Continued)Physical therapy and occupationaltherapy modalities, therapeuticprocedures, tests and measurements

1144

Admission to Acute Rehab Facility 1144

MISCELLANEOUS MEDICAL SERVICESCircadian respiratory pattern recording(pediatric pneumogram)

1144

Intracutaneous (intradermal) tests withallergenic extracts, delayed type reaction

1144

Unlisted allergy/clinical immunologicservice

1144

Unlisted special service, procedure,report

1144

Handling, conveyance, and/or otherservice associated with an orderinvolving devices fabricated by outsidelaboratories

1144

EPSDT SERVICESCase Management for Medically FragileChildren

1144

Skilled Nursing Visits 1144

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